NOT RECOMMENDED FOR PUBLICATION File Name: 22a0197n.06
Case No. 21-2739
UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT
SHERRY L. VANNORTWICK, in her ) FILED ) May 12, 2022 capacity as the Personal Representative of the ) DEBORAH S. HUNT, Clerk Estate of Claude Stevens, ) Plaintiff-Appellant, ) ) ON APPEAL FROM THE UNITED v. ) STATES DISTRICT COURT FOR ) THE EASTERN DISTRICT OF ANTHONY STEWART, et al., ) MICHIGAN Defendants, ) ) DR. VINDHYA JAYAWARDENA, ) ) Defendant-Appellee. )
Before: COLE, CLAY, and THAPAR, Circuit Judges.
THAPAR, Circuit Judge. Claude Stevens was a state prisoner who passed away from
kidney failure after his catheter dislodged and he couldn’t receive his regular dialysis. His estate
sued his prison doctor for deliberate indifference under the Eighth Amendment, and the district
court granted summary judgment to the doctor. We affirm.
I.
Before his death, Claude Stevens was a state prisoner in the custody of the Michigan
Department of Corrections. He suffered many ailments, including gastroesophageal reflux disease
(GERD) and kidney failure. To treat his kidney problems, Stevens received dialysis on Mondays, Case No. 21-2739, VanNortwick v. Stewart, et al.
Wednesdays, and Fridays. At times, he experienced complications like high potassium levels—
called hyperkalemia—which can occur if dialysis doesn’t filter the system well. Hyperkalemia
can cause cardiac arrest or even death.
Stevens had a permanent catheter to assist with dialysis. But one Saturday, his catheter
dislodged. Other inmates alerted nurse Larry Marshall about this early on Monday morning, and
Marshall saw Stevens in his office. Without the catheter in place, though, Stevens couldn’t receive
dialysis that day. So Marshall had Stevens’s blood drawn to make sure various blood chemical
levels were stable. And Marshall ordered the results “stat,” meaning they’d arrive within several
hours.
Between 10 and 10:40 a.m. on Monday morning, Stevens’s regular doctor—Dr. Vindhya
Jayawardena—heard about Stevens’s dislodged catheter and missed dialysis.1 At 10:42 a.m., Dr.
Jayawardena completed the paperwork to request a catheter replacement, which was scheduled for
the next morning. And wanting to evaluate Stevens herself, she set an appointment with him for
after 1 p.m. on Monday.
During their visit, Stevens told Dr. Jayawardena that he had been experiencing stomach
pains since Saturday night, when he ate rice and shredded beef for dinner. Sure enough, she noted
that he had nausea, abdominal tenderness, bloating, and was burping. But she found he otherwise
seemed stable and was standing and talking. So she suspected a GERD flareup, prescribed an
acid-reflux medication, and sent Stevens back to his cell.
1 Dr. Jayawardena regularly treated Stevens’s ailments, including his kidney failure and episodes of high potassium. She worked for Corizon—a healthcare group that the Michigan Department of Corrections contracted with to provide services to inmates.
-2- Case No. 21-2739, VanNortwick v. Stewart, et al.
After her evaluation, Dr. Jayawardena “sign[ed] out” Stevens’s care to one of her
subordinates—nurse practitioner Francis Awosika. R. 143, Pg. ID 2338. She called Awosika and
told him to look out for the labs that were to arrive within hours.
Sometime after 2:30 p.m., Stevens started vomiting dark material that looked like “feces.”
R. 142-13, Pg. ID 2148, 2180. No one told Dr. Jayawardena. Meanwhile, a couple hours after
that, Stevens’s lab results arrived unnoticed to a prison fax machine. Dr. Jayawardena, who
normally leaves around 5 p.m. at the latest, never saw the faxed results.
Stevens was taken to the prison healthcare unit around 7 p.m. Around that time, someone
alerted Awosika about Stevens’s lab results—his potassium levels were far over the safe range.
Awosika immediately called for an ambulance. Sadly, Stevens passed away about two hours later.
Sherry VanNortwick, Stevens’s personal representative, sued under 42 U.S.C. § 1983,
claiming deliberate indifference to his medical needs in violation of the Eighth Amendment. The
district court granted summary judgment for most defendants, and the parties stipulated to the
dismissal of all others. Stevens’s estate (Stevens) appeals only his claim against Dr. Jayawardena.
II.
A prison official violates the Eighth Amendment when he is deliberately indifferent to an
inmate’s serious medical needs. Estelle v. Gamble, 429 U.S. 97, 103–04 (1976). A deliberate-
indifference claim has both objective and subjective components.
The objective component asks whether the inmate suffered from a “sufficiently serious”
medical need. Farmer v. Brennan, 511 U.S. 825, 834 (1994) (citation omitted). This means either
a doctor diagnosed a condition as needing treatment or it was so obvious that even a layperson
would know the condition needed care. Phillips v. Tangilag, 14 F.4th 524, 534 (6th Cir. 2021).
-3- Case No. 21-2739, VanNortwick v. Stewart, et al.
The subjective component asks about the official’s state of mind. Rhinehart v. Scutt,
894 F.3d 721, 738 (6th Cir. 2018). To ensure the official acted with the required level of
culpability, the prisoner must establish that the official (1) was aware of facts from which she could
infer a substantial risk of serious harm to the prisoner’s health; (2) in fact drew that inference; and
(3) “consciously disregarded” the substantial risk. Id. at 736, 738. When an inmate challenges the
adequacy of care, instead of a lack of care entirely, we are “generally reluctant to second guess
medical judgments.” Richmond v. Huq, 885 F.3d 928, 939 (6th Cir. 2018) (citation omitted).
Simply put, a negligent misdiagnosis is not enough. Comstock v. McCrary, 273 F.3d 693, 703
(6th Cir. 2001) (citing Estelle, 429 U.S. at 106). “The doctor must have consciously exposed the
patient to an excessive risk of serious harm.” Rhinehart, 894 F.3d at 738–39 (cleaned up).
Even if Stevens could show that he has met his burden with regard to the objective
component, his case fails at the subjective prong.
Stevens first argues that Dr. Jayawardena must have inferred a substantial risk of harm
from hyperkalemia because Stevens’s medical history included previous episodes of
hyperkalemia, even when he didn’t miss dialysis. So, Stevens says, Dr. Jayawardena should have
sent him to the hospital immediately after discovering that he had been feeling sick since
Saturday’s dinner and didn’t receive dialysis on Monday morning.
True, Dr. Jayawardena knew of Stevens’s long- and short-term histories. But there is no
evidence that Dr. Jayawardena “consciously disregarded” a substantial risk of serious harm from
these histories. Id. at 736. Quite the opposite. First, Dr. Jayawardena requested a new catheter,
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NOT RECOMMENDED FOR PUBLICATION File Name: 22a0197n.06
Case No. 21-2739
UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT
SHERRY L. VANNORTWICK, in her ) FILED ) May 12, 2022 capacity as the Personal Representative of the ) DEBORAH S. HUNT, Clerk Estate of Claude Stevens, ) Plaintiff-Appellant, ) ) ON APPEAL FROM THE UNITED v. ) STATES DISTRICT COURT FOR ) THE EASTERN DISTRICT OF ANTHONY STEWART, et al., ) MICHIGAN Defendants, ) ) DR. VINDHYA JAYAWARDENA, ) ) Defendant-Appellee. )
Before: COLE, CLAY, and THAPAR, Circuit Judges.
THAPAR, Circuit Judge. Claude Stevens was a state prisoner who passed away from
kidney failure after his catheter dislodged and he couldn’t receive his regular dialysis. His estate
sued his prison doctor for deliberate indifference under the Eighth Amendment, and the district
court granted summary judgment to the doctor. We affirm.
I.
Before his death, Claude Stevens was a state prisoner in the custody of the Michigan
Department of Corrections. He suffered many ailments, including gastroesophageal reflux disease
(GERD) and kidney failure. To treat his kidney problems, Stevens received dialysis on Mondays, Case No. 21-2739, VanNortwick v. Stewart, et al.
Wednesdays, and Fridays. At times, he experienced complications like high potassium levels—
called hyperkalemia—which can occur if dialysis doesn’t filter the system well. Hyperkalemia
can cause cardiac arrest or even death.
Stevens had a permanent catheter to assist with dialysis. But one Saturday, his catheter
dislodged. Other inmates alerted nurse Larry Marshall about this early on Monday morning, and
Marshall saw Stevens in his office. Without the catheter in place, though, Stevens couldn’t receive
dialysis that day. So Marshall had Stevens’s blood drawn to make sure various blood chemical
levels were stable. And Marshall ordered the results “stat,” meaning they’d arrive within several
hours.
Between 10 and 10:40 a.m. on Monday morning, Stevens’s regular doctor—Dr. Vindhya
Jayawardena—heard about Stevens’s dislodged catheter and missed dialysis.1 At 10:42 a.m., Dr.
Jayawardena completed the paperwork to request a catheter replacement, which was scheduled for
the next morning. And wanting to evaluate Stevens herself, she set an appointment with him for
after 1 p.m. on Monday.
During their visit, Stevens told Dr. Jayawardena that he had been experiencing stomach
pains since Saturday night, when he ate rice and shredded beef for dinner. Sure enough, she noted
that he had nausea, abdominal tenderness, bloating, and was burping. But she found he otherwise
seemed stable and was standing and talking. So she suspected a GERD flareup, prescribed an
acid-reflux medication, and sent Stevens back to his cell.
1 Dr. Jayawardena regularly treated Stevens’s ailments, including his kidney failure and episodes of high potassium. She worked for Corizon—a healthcare group that the Michigan Department of Corrections contracted with to provide services to inmates.
-2- Case No. 21-2739, VanNortwick v. Stewart, et al.
After her evaluation, Dr. Jayawardena “sign[ed] out” Stevens’s care to one of her
subordinates—nurse practitioner Francis Awosika. R. 143, Pg. ID 2338. She called Awosika and
told him to look out for the labs that were to arrive within hours.
Sometime after 2:30 p.m., Stevens started vomiting dark material that looked like “feces.”
R. 142-13, Pg. ID 2148, 2180. No one told Dr. Jayawardena. Meanwhile, a couple hours after
that, Stevens’s lab results arrived unnoticed to a prison fax machine. Dr. Jayawardena, who
normally leaves around 5 p.m. at the latest, never saw the faxed results.
Stevens was taken to the prison healthcare unit around 7 p.m. Around that time, someone
alerted Awosika about Stevens’s lab results—his potassium levels were far over the safe range.
Awosika immediately called for an ambulance. Sadly, Stevens passed away about two hours later.
Sherry VanNortwick, Stevens’s personal representative, sued under 42 U.S.C. § 1983,
claiming deliberate indifference to his medical needs in violation of the Eighth Amendment. The
district court granted summary judgment for most defendants, and the parties stipulated to the
dismissal of all others. Stevens’s estate (Stevens) appeals only his claim against Dr. Jayawardena.
II.
A prison official violates the Eighth Amendment when he is deliberately indifferent to an
inmate’s serious medical needs. Estelle v. Gamble, 429 U.S. 97, 103–04 (1976). A deliberate-
indifference claim has both objective and subjective components.
The objective component asks whether the inmate suffered from a “sufficiently serious”
medical need. Farmer v. Brennan, 511 U.S. 825, 834 (1994) (citation omitted). This means either
a doctor diagnosed a condition as needing treatment or it was so obvious that even a layperson
would know the condition needed care. Phillips v. Tangilag, 14 F.4th 524, 534 (6th Cir. 2021).
-3- Case No. 21-2739, VanNortwick v. Stewart, et al.
The subjective component asks about the official’s state of mind. Rhinehart v. Scutt,
894 F.3d 721, 738 (6th Cir. 2018). To ensure the official acted with the required level of
culpability, the prisoner must establish that the official (1) was aware of facts from which she could
infer a substantial risk of serious harm to the prisoner’s health; (2) in fact drew that inference; and
(3) “consciously disregarded” the substantial risk. Id. at 736, 738. When an inmate challenges the
adequacy of care, instead of a lack of care entirely, we are “generally reluctant to second guess
medical judgments.” Richmond v. Huq, 885 F.3d 928, 939 (6th Cir. 2018) (citation omitted).
Simply put, a negligent misdiagnosis is not enough. Comstock v. McCrary, 273 F.3d 693, 703
(6th Cir. 2001) (citing Estelle, 429 U.S. at 106). “The doctor must have consciously exposed the
patient to an excessive risk of serious harm.” Rhinehart, 894 F.3d at 738–39 (cleaned up).
Even if Stevens could show that he has met his burden with regard to the objective
component, his case fails at the subjective prong.
Stevens first argues that Dr. Jayawardena must have inferred a substantial risk of harm
from hyperkalemia because Stevens’s medical history included previous episodes of
hyperkalemia, even when he didn’t miss dialysis. So, Stevens says, Dr. Jayawardena should have
sent him to the hospital immediately after discovering that he had been feeling sick since
Saturday’s dinner and didn’t receive dialysis on Monday morning.
True, Dr. Jayawardena knew of Stevens’s long- and short-term histories. But there is no
evidence that Dr. Jayawardena “consciously disregarded” a substantial risk of serious harm from
these histories. Id. at 736. Quite the opposite. First, Dr. Jayawardena requested a new catheter,
once she heard it had been dislodged, so that he could get dialysis again as soon as possible. Then,
on her own initiative, she personally evaluated Stevens and determined that none of his symptoms
called for immediate hospitalization. She provided a prescription for his symptoms—symptoms
-4- Case No. 21-2739, VanNortwick v. Stewart, et al.
that tracked another of his regular diseases (GERD). Plus, Dr. Jayawardena knew his lab results
were coming—lab results that would reveal if he also needed hyperkalemia treatment, including
specific medication or hospitalization. And something similar had happened before—Stevens
refused dialysis, Dr. Jayawardena ordered rushed labs to test for hyperkalemia, and there’s no
indication he ended up in the hospital. Finally, no one alerted Dr. Jayawardena that Stevens’s
condition worsened after she saw him.
Given these facts, Dr. Jayawardena was not providing treatment “so cursory as to amount
to no treatment at all.” Dominguez v. Corr. Med. Servs., 555 F.3d 543, 551 (6th Cir. 2009) (citation
omitted). Responding with care that aligned with the symptoms she saw and history she knew
about shows that she wasn’t consciously disregarding a substantial risk of serious harm. Rhinehart,
894 F.3d at 738–39; see Comstock, 273 F.3d at 703 (“When a prison doctor provides treatment,
albeit carelessly or inefficaciously, to a prisoner, he has not displayed a deliberate indifference to
the prisoner’s needs, but merely a degree of incompetence which does not rise to the level of a
constitutional violation.”).
Next, Stevens argues that Dr. Jayawardena consciously disregarded a substantial risk by
not checking for the lab results before leaving that day. But Dr. Jayawardena signed Stevens out
to nurse practitioner Awosika at 1:43 p.m. Thus, it was Awosika’s responsibility to watch for the
lab results. In fact, Dr. Jayawardena specifically asked Awosika to look out for them. And
Awosika recalls Dr. Jayawardena alerting him to the incoming labs since “she may not be there
when the lab results come in.” R. 142-2, Pg. ID 1671. So Dr. Jayawardena took steps toward
treating Stevens’s observable symptoms (GERD), diagnosing another problem from which
Stevens might be suffering (hyperkalemia), and making sure the next medical provider had all the
-5- Case No. 21-2739, VanNortwick v. Stewart, et al.
relevant information.2 Those steps show that she did not consciously disregard a substantial risk
to Stevens.
Finally, Stevens implies that Dr. Jayawardena should have known his nausea was a
symptom of hyperkalemia rather than GERD. But Stevens concedes that the only way to diagnose
hyperkalemia for sure is through a blood test—which Dr. Jayawardena knew was coming and told
Awosika about. What’s more, nausea is a symptom of many things. Given that, Stevens’s history
of gastrointestinal problems, and what he had eaten, Dr. Jayawardena thought he more likely had
GERD. Assuming nausea is also a symptom of hyperkalemia, it would be negligence at most if
Dr. Jayawardena did not know this. See Comstock, 273 F.3d at 703; Murray v. Dep’t of Corr.,
29 F.4th 779, 787 (6th Cir. 2022) (noting that medical mistakes are not enough). And again, most
importantly, Dr. Jayawardena told Awosika about the incoming results instead of consciously
disregarding Stevens’s potential harm. In sum, Stevens’s “disagreement with” his diagnosis and
treatment “does not rise to the level of an Eighth Amendment violation.” Rhinehart, 894 F.3d at
740 (citation omitted).3
* * *
Dr. Jayawardena treated a patient who was walking and talking, who didn’t appear to need
immediate hospitalization, and who was awaiting lab results that would confirm if he did need
serious treatment. After seeing that patient, she handed him off to her subordinate, who could act
on the results. Taken together, Dr. Jayawardena is entitled to summary judgment. We affirm.
2 Just because Awosika also had other patients to deal with doesn’t create a genuine dispute of material fact about Dr. Jayawardena handing over Stevens to Awosika. Dr. Jayawardena and Awosika both knew that Awosika would be the only provider at the prison after a certain point that day. That would make him responsible for any patient who needed immediate care. 3 It’s unclear if Stevens also argues that the serious medical need was his kidney failure rather than hyperkalemia. But even if he does, his claim still fails on the subjective prong. Dr. Jayawardena was regularly treating his ongoing kidney failure with dialysis three times a week. And the catheter outpatient procedure was set for as soon as possible. There is no dispute that sometimes patients miss a day of dialysis. His ongoing and rescheduled dialyses were not “so woefully inadequate as to amount to no treatment at all.” Richmond, 885 F.3d at 939 (citation omitted).
-6-